Tuesday, September 11, 2007

Health Care: We Will Get Old - if we're lucky

Aging ... if we're lucky we age. If we're lucky, we get to pass through all the different ages ... 5 years old ... 13 ... 21 .... 35 years old ... 40 .... 55 ... 62 (maybe retirement) ... 76 ... if we're lucky. And if we're supremely lucky, we'll age with good health care.

There's a really good article about all this in the April 30, 2007 edition of The New Yorker. The article is "The Way We Age Now" by Atul Gawande. Here's an excerpt:

Several years ago, researchers in St. Paul, Minnesota, identified five hundred and sixty-eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric specialists. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Several of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

But the finances are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policymakers make sure they are paid for. They feed our hope that the troubles of the body can be fixed for good. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations. And it requires each of us to contemplate the course of our decline, in order to make the small changes that can reshape it. When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.